UNIVERSITY OF SANTO TOMAS HOSPITAL

Espana Blvd., Manila 1008

Tel No. (632)731-3001 to 29; http://www.usthospital.com.ph
Department of Pediatrics

CASE PROTOCOL

JASB
DOB: 01/01/2009
DOA: 02/22/2020

CC: Vomiting

11 years prior to admission, patient was unable to pass meconium within 48 hours after birth. This was
accompanied by multiple episodes of nonbilious, nonprojectile vomiting and poor feeding. He was admitted for 2
weeks at the NICU, treated as a case of Neonatal sepsis and was given unrecalled IV antibiotics. Work-up for
Hirschsprung disease was likewise done. Barium enema showed gaseous distension of the large and small
intestines (rectosigmoid); tapered narrowing of the distal portion of the rectum and dilated sigmoid and
descending colon, suggestive of Hirschsprung disease. Rectal biopsy was also done and was negative for
ganglion cells confirming the diagnosis of Hirschsprung disease.

Interval history revealed that the patient had irregular bowel movement occurring 3-4x/week, Bristol Type 1-2
described to be mostly hard, small pellet-like, scybalous. This was accompanied by irritability and difficulty
passing out stools. Mother self medicated with glycerin suppository as needed which provided relief. No consult
or follow up was done at this time.

Nine years prior to admission, patient had multiple episodes of non-bilious, nonprojectile vomiting accompanied
by loose stools. Patient was assessed with Acute gastroenteritis and was admitted for a week, hydrated and was
given unrecalled medications. Patient was discharged stable, but was advised to consult with a pediatric
surgeon. However, he was lost to follow up.

Seven years prior to admission, patient had abdominal distention with no fever, abdominal pain or vomiting.
Barium Enema was done and showed progressive increase in gaseous distention of colon filled with fecal
material. Patient was advised colostomy, but this was not done since patient had Dengue Fever on admission
and the family had financial constraints. They were then advised and instructed to do routine colonic irrigation
instead.

Interval history revealed that the patient was not compliant with regular colonic irrigation. He still had irregular
bowel movement occurring 1-3x/week, Bristol Type 1-2, still described to be hard, small pellet-like, scybalous.
There was also recurrent abdominal distention which was relieved by bowel movement. Glycerin suppository was
given once a week and the patient was once again lost to follow up.

One day prior to admission, patient had 4 episodes of vomiting, bilious, non-projectile amounting to ½ cup per
episode. This was accompanied by abdominal pain described to be diffuse, crampy, intermittent, graded 3/10,
abdominal distention and loss of appetite. He was given Bisacodyl suppository, but there was no bowel
movement at this time.

Few hours prior to admission, there was persistence of abdominal pain with progression of abdominal
enlargement. There was also loss of appetite and generalized weakness, Patient had 5 episodes of bowel
movement, Bristol type 6-7, non-bloody, non-mucoid amounting to ½ cup per episode and 6 episodes of
vomiting, non-bilious, non-projectile amounting to ½ cup per episode prompting ER consult and subsequent
admission.

Review of Systems:
General: (+) poor weight gain
Cutaneous: (-) rashes, (-) jaundice, (-) pruritus, (-) hair loss
HEENT: (-) headache, (-) dizziness, (-) eye itchiness, (-) redness, (-) discharge, (-) ear pain, (-) aural discharge,
(-) tinnitus, (-) nasal congestion, (-) epistaxis, (-) sore throat
Respiratory: (-) cough, (-) colds, (-) dyspnea
Cardiac: (-) cyanosis (-) easy fatiguability
Genitourinary: (-) dysuria, (-) frequency, (-) urgency, (-) nocturia
Endocrine: (-) polyuria, (-) polydipsia, (-) polyphagia, (-) cold/heat intolerance
 UNIVERSITY OF SANTO TOMAS HOSPITAL
Espana Blvd., Manila 1008
Tel No. (632)731-3001 to 29; http://www.usthospital.com.ph
Department of Pediatrics

Neurologic: (-) tremors, (-) loss of consciousness, (-) seizure, (-) behavioral change
Musculoskeletal: (-) limitation of movement, (-) bone, joint or muscle pain
Hematologic: (-) easy bruisability, (-) gum bleeding, (-) pallor

Immunization History:
Vaccine Expected Date Given Adverse Reaction Place Given
BCG At birth Unrecalled None Dimasalang Health
Center
Hepatitis B At birth Unrecalled None Dimasalang Health
Center
OPV 1, 2, 3 6, 10, 14 weeks Unrecalled None Dimasalang Health
Center
DTP-Hep B-Hib 1, 6, 10, 14 weeks Unrecalled None Dimasalang Health
2, 3 Center
IPV 14 weeks Unrecalled None Dimasalang Health
Center
Measles 9 months Unrecalled None Dimasalang Health
Center
MMR 12 months Unrecalled None Dimasalang Health
Center
Varicella 12 months Unrecalled None Dimasalang Health
Center

Feeding History:
Food Intake Calories
Breakfast 2 Fudgee bars 290 kcal
Lunch 2 cups rice + 1 portion of meat 505 kcal
PM Snacks 3 Hansel sandwiches + 4 Fudgee 510 kcal
bars
Dinner 1/3 cup rice + soup (meat) 343 kcal
ACI 1638 kcal
RENI 2060 kcal
% deficiency 20.5%

Food preferences:
Rice with fish/chicken
Not fond of vegetables and fruits
Water intake: ~1L/day

HEADSSS:
Home: lives with parents, 2 siblings and maternal grandmother; has good relationship with family; shares room
with siblings
Education: grade 5 student with average grades; favorite subject is Math; least favorite is English; dreams of
becoming a teacher
Activities: member of various organizations in school; plays badminton; fond of mobile games and watching
videos online
Drugs: denies illicit drug use, cigarette smoking and drinking alcoholic beverages; guardians are role models
Safety: rides a jeepney to school with mother; follows traffic rules; uses the pedestrian lane for crossing; knows
the importance of wearing seatbelt in automobiles
Sexuality: identifies as male; no crushes/love interest
Suicide/Depression/Self-Image: has 3 best friends (1 boy and 2 girls); does not have low self esteem; his
disease does not affect him psychosocially; has no history or thoughts of self-harm or harming others

Past Medical History:

Dengue Fever (2013)
No known allergies
No previous surgeries
 UNIVERSITY OF SANTO TOMAS HOSPITAL
Espana Blvd., Manila 1008
Tel No. (632)731-3001 to 29; http://www.usthospital.com.ph
Department of Pediatrics

Family History
(+) Stroke– paternal grandfather
(+) Hypertension– maternal grandfather
(-) Allergies/Asthma, (-) Tuberculosis
(-) Diabetes, (-) Thyroid Disorders
(-) Cancer/Malignancies, (-) Blood dyscrasia

Family Profile:
Age Educational attainment Occupation Health Status
Father 36 High school graduate Government Healthy
employee
Mother 32 High school graduate None Healthy
Brother 10 Elementary Student Healthy
Sister 4 Kindergarten Student Healthy

Environmental History:
Lives in a 1-storey, well-lit, well-ventilated apartment
No nearby factory, construction, major roads or waterway
Drinking water from refilling station
Garbage collected daily
Has 2 pet dogs
With cigarette smoke exposure from maternal grandmother

Physical Examination:
General Survey: conscious, coherent, not in respiratory distress, undernourished, moderately dehydrated, ill-
looking, carried
Vital signs:BP 100/70 mmHg HR 112 bpm RR 18 cpm Temp 36.5 SpO2 98%
Anthropometrics: Wt 25kg Ht 135cm (z-score below -1) BMI 13.72 (z-score below -2)
Nutritional status: Not stunted; Wasted

Skin: warm, moist, no active dermatoses

Head: equal hair distribution, no nits or lice
Eyes: (+) sunken eyeballs, pink palpebral conjunctivae, anicteric sclerae, 2-3mm equally reactive to light
Ears: (-) tragal tenderness, non-hyperemic external auditory canal, (+) retained cerumen AU, intact tympanic
membrane
Nose: (-) alar flaring, septum midline, non-congested turbinates, nasal discharge
Throat/Mouth: (+) dry lips and buccal mucosa, (-) sores or ulcers, tonsils not enlarged, non-hyperemic
posterior pharyngeal wall
Neck: no palpable lymph nodes, thyroid gland not enlarged
Chest/lungs: symmetrical chest expansion, no retractions, resonant, clear breath sounds
Heart: adynamic precordium, apex beat at 5th left intercostal space midclavicular, (-) heaves, lifts, thrills,
murmurs
Abdomen: distended, AC 63.5cm, normoactive bowel sounds (12 clicks), tympanitic on RUQ and LUQ, (+)
dullness on RLQ and LLQ, soft, (+) hard irregular palpable mass at LLQ, non-tender on all quadrants
Genitourinary: grossly male (Tanner stage 2), bilaterally descended testes
Extremities: no gross deformities, pulses full and equal, capillary refill time <2s
DRE: (-) anal fissures, (-) skin tags, (-) palpable masses, tight sphincteric tone, full rectal vault, (+) soft stools
on examining finger, (+) gush of air

Neurologic Examination

Cerebral: conscious, coherent

Cranial Nerves:
CN I – intact
CN II – pupils 2-3 mm, ERTL, (+) direct and consensual light reflex
CN III, IV, VI – EOMs full and intact
CN V – no sensory deficits on V1 V2 and V3, muscle of mastication intact
 UNIVERSITY OF SANTO TOMAS HOSPITAL
Espana Blvd., Manila 1008
Tel No. (632)731-3001 to 29; http://www.usthospital.com.ph
Department of Pediatrics

CN VII –able to smile, frown, raise eyebrows, no facial asymmetry

CN VIII – gross hearing intact
CN IX, X – uvula midline, (+) gag reflex
CN XI – can shrug shoulders; turn head side to side against resistance
CN XII – tongue midline
Motor: MMT 5/5 on all extremities
Cerebellar: no dysmetria, no dysdiadochokinesia
Sensory: no sensory deficit on all extremities
Reflexes: DTR ++ on both upper and lower extremities
Meningeal: (-) Nuchal rigidity (-) Brudzinski (-) Kernig’s

Assessment: Hirschsprung associated Enterocolitis with Lower GIT Obstruction; Wasted; Moderately
dehydrated

Course in the Ward:

On admission, patient was placed on NPO. NGT inserted.
CBC, Serum Na, K, Cl, BUN, Crea, Urinalysis, SFA were requested.
 CBC Hgb 140, Hct 0.44, Plt 507, WBC 9.5 (Seg 57, Lym 39, Eos 4)
 Urinalysis: Light yellow, clear, pH 6.0, SG 1.015, Alb (-), Sug (-), no RBC, Pus 0-1, Bact few
 Na 132, K 3,77, Cl 95.6, BUN 10.7, Crea 0.38
 Scout film of the abdomen: negative for pneumoperitoneum; with multiple fecal materials seen
throughout the colonic segments in a known case of Hirschsprung’s disease; marked dilatation of the
transverse colon; small bowel segments within the normal limits and with no abnormal calcifications and
soft tissue mass seen

Patient was referred to Pediatric Surgery & Pediatric Gastroenterology. Started IVF: D5LRS at moderate and the
following antibiotics: Ampicillin 160mg/kg/day, Gentamicin 8 mg/kg/day & Metronidazole 30 mg/kg/day

On the 1st hospital day, no vomiting episodes, no abdominal pain, no fever. Patient had stable vital signs.
Abdomen was distended at 63 cm, with normoactive bowel sounds (8 clicks/min), dull on RLQ and LLQ. There
was noted palpable mass at LLQ. No tenderness on all quadrants. Colonic irrigation was done twice daily, with
stools noted to be brown & mushy. Losses were replaced by PLRS volume per volume.

On the 2nd hospital day, no vomiting episodes, no abdominal pain, no fever. Patient had stable vital signs.
Abdomen was distended at 61 cm, with normoactive bowel sounds (10 clicks/min), dull on RLQ and LLQ. There
was noted palpable mass at LLQ. No tenderness on all quadrants. Colonic irrigation was continued twice daily,
with stools still brown & mushy. NGT drain was non-bilious. Repeat SFA showed: Negative for
pneumoperitoneum. Multiple fecal materials seen throughout the colonic segments in a known case of
Hirschsprung’s disease. There was marked dilatation of the transverse colon. Small bowel segments were within
the normal limits. No abnormal calcifications and soft tissue mass were seen. Present management was
continued.
 UNIVERSITY OF SANTO TOMAS HOSPITAL
Espana Blvd., Manila 1008
Tel No. (632)731-3001 to 29; http://www.usthospital.com.ph
Department of Pediatrics

On the 4th hospital day, no vomiting episodes, no abdominal pain, no fever. Patient had stable vital signs.
Abdominal circumference at 59 cm, with normoactive bowel sounds (12 clicks/min), dull on RLQ and LLQ. There
was still a noted palpable mass at LLQ. No tenderness on all quadrants. Colonic irrigation was continued twice
daily, with stools noted to still be brown & mushy. NGT drain had minimal output of non-bilious fluid. Repeat
serum Na 141, and K 2.84, hence IVF fluid was shifted to D5IMB + 15 mEqsKCl at 100%.

On the 5th hospital day, abdominal circumference at 59 cm, still with normoactive bowel sounds (9 clicks/min),
dull on RLQ and LLQ and palpable mass at LLQ. Repeat Na: 139, K 3.81. IVF shifted to D5LRS at 100%. Patient
was started on clear liquids and Lactulose once a day at bedtime.

On the 7th hospital day, abdomen was less distended at 56 cm, barium enema was requested which showed
barium dye up to distal descending colon, transition zone seen 4cm from anal verge, rectosigmoid index 0.3.
Post-evacuation film showed marked retention of barium enema

Feeding progressed to general liquids. Antibiotics were completed.

Barium dye up to distal descending colon, transition zone seen 4cm from anal verge, rectosigmoid index 0.3.
 UNIVERSITY OF SANTO TOMAS HOSPITAL
Espana Blvd., Manila 1008
Tel No. (632)731-3001 to 29; http://www.usthospital.com.ph
Department of Pediatrics

Post-evacuation film: marked retention of barium enema

On the 12th hospital day, abdomen was less distended at 55 cm. Patient was scheduled for Sigmoid Loop
Colostomy with Biopsy. Pre-op medication given: Cefoxitin 500 mg/slow infusion over 30 mins. Frozen section
done on normal segments showed presence of ganglion cells.

On the 13th hospital day (Day 1 post-op), patient had minimal post-op site pain, no vomiting or fever and with
stable vital signs. There was colostomy bag at the right, abdomen was normoactive (10 clicks/min), with palpable
mass at LLQ. Colostomy output: 20 mL. Patient maintained on NPO for now. Post-op medications of Cefoxitin
86mkday for 3 days, Paracetamol 13mkdose Q6 PRN, Ketorolac Q6 for 24 hrs& Nalbuphine Q4 PRN were given.

On the 17th HD (Day 5 post-op, there was no abdominal pain, fever, vomiting and px had stable vital signs.
Colostomy output: 140 mL. Diet was progressed and patient was discharged and parents were instructed on
proper colostomy care. Take home-medications include Paracetamol 13mkdose Q6 PRN for pain and
Multivitamins 10 ml once daily.

Procedure Done: Sigmoid Loop Colostomy with Biopsy

Final diagnosis: Hirschsprung Associated Enterocolitis; Hirschsprung Disease s/p Sigmoid Loop Colostomy;
Wasted